New York Life Insurance Company

Transcription

1 New York Life Insurance Company A Mutual Company Founded in Madison Avenue, New York, NY GROUP ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE CERTIFICATE ( CERTIFICATE ) POLICYHOLDER POLICY NUMBER CONTRACT STATE TRUSTEE UNDER TRUST AGREEMENT WITH THE INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS, INC. G (the "Policy") DISTRICT OF COLUMBIA NEW YORK LIFE certifies that, as stated on the When Insurance Takes Effect page(s), a person becomes a COVERED PERSON on the CERTIFICATE EFFECTIVE DATE stated on the Individual Schedule of Benefits. Insurance is subject to: (a) any exclusions and limitations of the Policy and all other terms and conditions of the Policy; and (b) New York Life's underwriting requirements. No Interim Liability New York Life is not liable for requested insurance on any person while a request for such insurance is being processed, even if New York Life has accepted a remittance for such requested insurance. New York Life will not be liable for such insurance if the request is not formally approved and will return any such premium remittance. Renewal Insurance under the Policy will be renewed automatically on each Anniversary Date if its terms and conditions are met. Insurance for an INSURED MEMBER will be renewed automatically on each RENEWAL DATE for an INSURANCE PERIOD if the terms and conditions of the Policy are met. On all stated days and dates, insurance begins at 12:01 A.M. and insurance ends at midnight at the place the INSURED MEMBER resides. Highlights and other details of insurance appear in the Individual Schedule of Benefits page(s) in the State Regulations page(s), if any. These pages are attached to and made a part of the Certificate. This Certificate replaces all Certificates and Certificate Riders, if any, previously issued to an INSURED MEMBER under the Policy. Right To Examine The Certificate For 30 Days Except for TRANSFER INSURANCE, an INSURED MEMBER will have 30 days from the date of receipt to examine the initial certificate. If the INSURED MEMBER does not wish to keep the initial certificate, it must be surrendered to New York Life within this period. Upon such surrender, New York Life will return any premium paid and insurance will be void from the start. Secretary President G /CERT 7/1/10 GMR-FACE

2 TABLE OF CONTENTS DEFINED TERMS ARE ALL CAPITALIZED. PLEASE REFER TO THE DEFINITIONS PAGES. Pages Pages G GMR-TABLE 2-3 IMPORTANT NOTICE DEFINITIONS 3-4 WHEN INSURANCE TAKES EFFECT --- "STATE" REGULATIONS 4-8 AD&D INSURANCE --- SCHEDULE 9 WHEN INSURANCE ENDS --- INDIVIDUAL SCHEDULE OF 9 10 CONTINUANCE BENEFITS IMPORTANT NOTICE Certificate The Certificate is a summary of the provisions of the Policy. It should be kept in a safe place. It is not a contract of insurance. Any conflict between the terms of the Certificate and the Policy will be decided in favor of the Policy. A copy of the Policy is available at the Policyholder s office for inspection at any time during business hours. The INSURED MEMBER should contact New York Life with questions regarding insurance. Claims A claim should be submitted in accordance with the following: Notice Of Claim The claimant must write to New York Life about a claim within 30 days after the occurrence of any loss covered by the Policy. Failure to give notice within such time shall not invalidate nor reduce any claim if it can be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. Claim Forms New York Life will send the claimant claim forms within 15 days after notice of claim is received. If New York Life does not send the forms within 15 days, the claimant can send written proof of claim. The claim form or proof must show the date, cause and extent of the loss. Proof Of Loss New York Life must receive satisfactory proof of the loss within 90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it was not reasonably possible to furnish such proof within such time, provided such proof is furnished as soon as reasonably possible. Claims Payment The benefit is payable within 30 days after receipt of satisfactory proof of the covered loss. Legal Action The claimant cannot start any legal action: (a) within 60 days after a claim form or proof of loss is sent; or (b) more than three years after a claim form or proof of loss is due. Errors Errors, or delays in keeping records, will: (a) not revoke insurance otherwise in force; (b) not continue insurance which otherwise would have ended; and (c) upon discovery, require fair adjustment of remittances and/or insurance to correct the error. Examination New York Life, at its own expense, has the right and opportunity to: 1. have a person, for whom claim is made, examined: (a) physically; (b) psychologically; and/or (c) psychiatrically; to determine the existence and/or cause of any loss, other than loss of life. This right can be used as often as it is reasonably required while a claim is pending; and/or 2. in the event of loss of life: (a) reasonably request an autopsy where it is not forbidden by law or religious belief; and/or (b) examine the medical records of the deceased; to determine the cause of the loss. G GMR-C-NOTICE

3 IMPORTANT NOTICE Incontestability Except for nonpayment of CONTRIBUTIONS, New York Life cannot contest the validity of any insurance on a COVERED PERSON after it has been in force for two years prior to the contest under the Policy during such COVERED PERSON'S lifetime. To contest, New York Life will only rely upon: (a) written statements signed by the INSURED MEMBER and/or his or her INSURED DEPENDENT in applying for such insurance: (1) under the Policy; and/or (2) under another policy, if such statements are used to allow insurance to take effect under or be transferred to the Policy; and/or (b) the provisions on the When Insurance Takes Effect page(s). A copy of all statements must be furnished to such person or to his or her beneficiary. Such statements are representations, not warranties. The time insured under the PREVIOUS POLICY for TRANSFER INSURANCE will also be used to determine if the two year contestable period has elapsed. Misstatements Subject to the Errors and Incontestability sections, if relevant statements of age or facts were not accurate for any person: (a) a fair adjustment of remittances and/or insurance will be made; and (b) based upon the facts, New York Life will decide whether, and what, insurance is valid under the Policy. Policy Changes The Policy can be changed: (a) at any time by written agreement between New York Life and the Policyholder; and (b) without the consent of any other person. Changes will be valid only if evidenced by an amendment to the Policy. Such amendment must be signed by the Policyholder and New York Life. The Policy may also be changed by New York Life by amendment to the Policy and without the consent of the Policyholder or any other person, if such amendment is signed by New York Life and: (a) results from the exercise of a right reserved to New York Life in the Policy; (b) is issued to conform to any law and/or regulation which, in New York Life's sole judgment, applies to the insurance under the Policy; or (c) results from the termination or change in an agreement between New York Life and a third party, if such agreement is separate and distinct from the Policy and provided the Policyholder is not a party to such agreement. No agent of New York Life can make or change the Policy or waive any of its provisions. Termination By The Policyholder The Policyholder may terminate the Policy, only after the first Anniversary Date, by giving written notice to New York Life at least 90 days in advance. Termination By New York Life New York Life may terminate the Policy, only after the first Anniversary Date, by giving written notice to the Policyholder at least 90 days in advance. G GMR-C-NOTICE WHEN INSURANCE TAKES EFFECT Requests An APPLICANT can request to become initially insured for MEMBER INSURANCE or MEMBER INSURANCE and DEPENDENT INSURANCE for each of his or her ELIGIBLE DEPENDENTS, subject to the Principal Sums Available section stated on the Schedule page(s). TRANSFER INSURANCE on each APPLICANT or each APPLICANT and each of his or her ELIGIBLE DEPENDENTS will automatically be transferred to the Policy on the TRANSFER DATE. For Insurance To Take Effect For insurance to take effect: 1. the APPLICANT must give the Policyholder a completed, written request for the insurance on a form satisfactory to New York Life. A written request for TRANSFER INSURANCE must be given within 31 days after the TRANSFER DATE. New York Life will treat a request for insurance submitted to the carrier of the PREVIOUS POLICY as a request for insurance submitted to New York Life; 2. the APPLICANT must pay the CONTRIBUTION no later than the initial RENEWAL DATE. Any contribution paid under the PREVIOUS POLICY for such insurance, covering the period on or after the CERTIFICATE EFFECTIVE DATE, will be applied to insurance under the Policy; 3. the proposed COVERED PERSON must be performing the normal activities of a person in good health of like age on the CERTIFICATE EFFECTIVE DATE (the normal activities requirement does not apply to TRANSFER INSURANCE); 4. New York Life must approve the insurance; and G GMR-TE

4 WHEN INSURANCE TAKES EFFECT 5. for DEPENDENT INSURANCE, the APPLICANT must be an INSURED MEMBER on the INSURED DEPENDENT'S CERTIFICATE EFFECTIVE DATE. Subject to the exception stated below, the effective date of insurance is the first day of the policy month on or after the day all these requirements are met. Subsequent Child - If the APPLICANT has DEPENDENT INSURANCE in force for children, any child he or she later acquires will become insured on the day such child first becomes an ELIGIBLE CHILD. Exception: The CERTIFICATE EFFECTIVE DATE for a proposed COVERED PERSON who was not performing the normal activities of a person in good health of like age on the date such insurance would otherwise have taken effect is the day the proposed COVERED PERSON is performing such normal activities, if: (a) such day is within three months of the date insurance would otherwise have taken effect; (b) for DEPENDENT INSURANCE, the APPLICANT is an INSURED MEMBER or a SURVIVOR SPOUSE on that day; and (c) the proposed COVERED PERSON is still eligible to obtain the insurance on that day. If these requirements are not satisfied, insurance will not take effect. No benefits will be paid for any loss occurring before the CERTIFICATE EFFECTIVE DATE. G GMR-TE AD&D INSURANCE New York Life will pay a benefit for a COVERED PERSON'S Covered Loss in accordance with all of the following: Covered Loss A Covered Loss is a loss that: 1. except as stated in the Disappearance and Exposure liberalizations, a COVERED PERSON suffers, but only if such loss results from an accidental injury and such: (a) loss occurs within 365 days of such injury; (b) injury occurs while he or she is insured under the Policy; and (c) injury is the direct result of the accident and is independent of all other causes. Termination of the Policy or of a COVERED PERSON S insurance will not prejudice the payment of benefits for a Covered Loss which resulted from an accidental injury that occurred before the date of such termination. Disappearance - If the COVERED PERSON is riding in a conveyance and such conveyance either disappears or sinks as the result of an accident and the COVERED PERSON'S body is not found within one year after the accident, New York Life will presume the COVERED PERSON suffered a loss of life due to an accidental injury within 365 days of such accident. Exposure Benefit If a COVERED PERSON suffers a loss listed in the Table of Benefits as a result of exposure to the elements, resulting from the forced landing, stranding, sinking or wrecking of a conveyance in which the COVERED PERSON was an occupant, such loss will be considered to be a Covered Loss resulting from an accidental injury; 2. is listed on the Table Of Benefits on the Schedule page(s); and 3. is not excluded in the Exclusions section. Exclusions The following losses are excluded: Air Travel - A loss that occurs during or is a direct result of the COVERED PERSON S travel in, travel on, fall from or descent from any aircraft while such aircraft is in flight, unless the COVERED PERSON is traveling solely as a passenger. Crime/Illegal Occupation/Illegal Activity A loss that: (a) occurs during; (b) is due to; or (c) is related to; the COVERED PERSON S participation in or incarceration resulting from any of the following in a role other than as a victim: (a) the commission of a felony; (b) an illegal occupation or activity; (c) an insurrection; (d) terrorist activity; or (e) a riot. Disease/Infirmity - A loss that is due to or related to: (a) disease or bodily infirmity of mind or body; (b) medical or surgical treatment of such disease or bodily infirmity; or (c) bacterial infections, except infections which occur as the result of an: (1) accidental cut or wound; or (2) accidental ingestion of contaminated material. G GMR-ADD

5 AD&D INSURANCE Drugs A loss that: (a) occurs during; (b) is due to; or (c) is related to; the COVERED PERSON S: (a) voluntary use of illegal drugs; (b) intentional taking of over the counter medication not in accordance with recommended dosage and warning instructions; or (c) intentional misuse of prescription drugs. Self-Inflicted Injury/Suicide - A loss that: (a) is due to or is related to: (1) suicide; (2) an attempt at suicide; or (3) an intentionally self-inflicted injury; (b) occurs during an attempt at suicide; or (c) occurs while intentionally injuring oneself; while the COVERED PERSON is sane or insane. Treatment - A loss that: (a) occurs during; (b) is due to; or (c) is related to; any medical, dental or surgical treatment unrelated to the accident which would otherwise entitle the COVERED PERSON to benefits. War Conditions - A loss that: (a) occurs during; (b) is due to; or (c) is related to; the COVERED PERSON'S engagement in any of the following in a role other than as a victim: (a) in war, (b) an act of war, or (c) an armed conflict which involves the armed forces of one or more countries. For The Benefit To Be Paid For a Covered Loss to be paid, New York Life must: (a) receive satisfactory proof of the COVERED PERSON'S loss within 90 days after such loss. If it is not possible to give proof within such 90 day period, it must be given as soon as reasonably possible; and (b) determine that the loss is a Covered Loss. What Benefit Is Payable The benefit payable for a Covered Loss is the applicable percentage of the Principal Sum in force for the COVERED PERSON on the date of the Covered Loss, as stated in the Table Of Benefits on the Schedule page(s). The benefit is payable within 30 days after receipt of satisfactory proof. A single payment is made unless payment in installments has been elected in accordance with the Payment In Installments and Request Procedure sections. New York Life will pay interest on the Death Benefit from the date of the COVERED PERSON S death until the date of payment. Interest will be paid at the greater of the annual interest rate declared by New York Life for policy proceeds left with New York Life under Option 1 (Proceeds at Interest) or the minimum required by state law. In addition to the benefits payable for a Covered Loss, a COVERED PERSON under age 70 may be entitled to the benefits outlined below. Adaptive Home/Auto Benefit An additional benefit is payable which is equal to the lesser of: (a) 5% of the Principal Sum; or (b) $5,000 of actual expenses incurred for necessary modifications to the COVERED PERSON S home and/or automobile required to accommodate physical disabilities due to a Covered Loss that is the result of an accident. Burn Disfigurement Benefit An additional benefit is payable for a Covered Loss that results from an accident and which causes the COVERED PERSON to suffer a disfigurement due to burns covering at least 5% of his/her body. The benefit amount is equal to the lesser of: (a) 10% of the Principal Sum; or (b) $30,000. Common Carrier Benefit - If the Covered Loss is the result of an accident while the COVERED PERSON is a passenger on a Common Carrier, an additional $25,000 is payable. Common Carrier means a conveyance operated by a concern, if: (a) such concern is organized and licensed for the transportation of passenger for hire; and (b) such conveyance is operated by an employee of such concern. Common Disaster Benefit - New York Life will pay a benefit for a COVERED PERSON S loss of life if as a result of the same or separate accidents that occur within the same 24-hour period, the INSURED MEMBER and his or her INSURED SPOUSE die within one year of such accident(s). The percentage applicable for the INSURED SPOUSE'S Covered Loss for loss of life will be increased to 100% of the INSURED MEMBER'S Principal Sum if: (1) the INSURED MEMBER and INSURED SPOUSE are survived by one or more ELIGIBLE CHILDREN; and (2) the combined benefits of the INSURED MEMBER and INSURED SPOUSE do not exceed $500,000. Day Care Benefit - New York Life will pay an additional benefit if an INSURED MEMBER S death is a Covered Loss and: 1. at the time of such INSURED MEMBER S death, his or her child is under age 13 and enrolled in a DAY CARE PROGRAM; and 2. satisfactory proof of enrollment, as described below, is provided to New York Life prior to the last day of the 12 th month on or next following the INSURED MEMBER S death. If it is not possible to give proof within such period, it must be given as soon as reasonably possible. G GMR-ADD

6 AD&D INSURANCE The benefit amount is the lesser of: (a) 5% of the amount payable under the INSURED MEMBER S Principal Sum Amount; or (b) $2,500, or (c) the actual amount of Day Care costs for one year. The benefit is paid each year for each child who qualifies for the Day Care Benefit, except that no more than four Day Care Benefits will be paid for each such child. The benefit will be paid to the child s legal representative. Proof of the child s enrollment in an approved DAY CARE PROGRAM may include, but not be limited to, the following: 1. a copy of the child s approved enrollment application in an approved DAY CARE PROGRAM; 2. canceled check(s) which prove payment to an approved DAY CARE PROGRAM; and 3. correspondence from the DAY CARE PROGRAM confirming that the child is attending the program or has been enrolled in the program and will be attending such program within 365 days of the INSURED MEMBER S death. If the INSURED MEMBER does not have a child eligible for this benefit at the time of the INSURED MEMBER S death, New York Life will pay a flat benefit of $500. DAY CARE PROGRAM is a child care program which: 1. is operated in a private home, school or other facility; and 2. provides and charges a fee for the care of children; and 3. is licensed as a Day Care Center or is operated by a licensed Day Care Provider, if such licensing is required by the state or jurisdiction in which it is located; or if licensing is not required, provides childcare on a daily basis for 12 months a year; and 4. is not provided by an immediate relative of the child receiving the care. An immediate relative is a sibling, parent, stepparent, grandparent, aunt or uncle. Education Benefit New York Life will pay an additional benefit if an INSURED MEMBER S death is a Covered Loss and such INSURED MEMBER has an ELIGIBLE SPOUSE and/or ELIGIBLE CHILD(REN), (excluding those who are ELIGIBLE MEMBERS), who, at the time of such INSURED MEMBER S death: 1. is a student attending an accredited post-secondary educational institution, including but not limited to a college or a vocational or technical school on a full-time basis as determined by such institution; or 2. is within 12 months of attending such institution and provides proof of enrollment in such institution. The benefit payable is the lesser of: (a) 2% of the INSURED MEMBER S Principal Sum in force on the date of his or her death; (b) $2,500; or (c) the actual amount of the tuition charge for one school year. The benefit is payable each year for up to four consecutive years, except that: The benefit will end for such student if he or she ceases to qualify as a student as stated above. The benefit payable for an INSURED MEMBER S ELIGIBLE SPOUSE is payable to such ELIGIBLE SPOUSE. The benefit payable for an INSURED MEMBER S ELIGIBLE CHILD(REN) is payable to such ELIGIBLE CHILD(REN), except that if such ELIGIBLE CHILD(REN) is a minor, the benefit will be paid to an INSURED MEMBER S legal representative. If the INSURED MEMBER does not have a dependent eligible for this benefit at the time of the INSURED MEMBER S death, New York Life will pay 4% of the Principal Sum. Elder Care Benefit New York Life will pay an additional benefit if: (a) a COVERED PERSON S death is a Covered Loss; and (b) such COVERED PERSON S elderly relative (other than a spouse) was dependent on the COVERED PERSON for support and maintenance. The benefit amount is equal to the lesser of: (a) 5% of the Principal Sum; or (b) $5,000. Rehabilitation Benefit If a COVERED PERSON incurs a Covered Loss for other than loss of life, an additional benefit may be payable for participation in a rehabilitation program. The benefit is equal to the lesser of: (a) 10% of the Principal Sum; (b) $10,000. Such cost must be incurred within two years of the Covered Loss. However, the nature of the rehabilitation program and the extent of participation by the COVERED PERSON and by New York Life must be satisfactory to both and stated in a written rehabilitation program agreement before any such program can take effect. G GMR-ADD

7 AD&D INSURANCE Any benefits for Total Disability otherwise payable to a COVERED PERSON will continue to be payable during participation in an approved rehabilitation program. In order to be considered for participation in a rehabilitation program, a COVERED PERSON must give New York Life: (a) a written request in which the COVERED PERSON consents to an evaluation of his or her rehabilitation and vocational potential; and (b) all written authorization necessary for the conduct of such evaluation by New York Life or a rehabilitation service or agency selected by New York Life. New York Life may approve a COVERED PERSON S participation in a rehabilitation program for a period of three consecutive months and may approve extension or renewals of such participation for one or more additional like or shorter periods. A COVERED PERSON S participation in a rehabilitation program will terminate at the end of the period of participation last approved by New York Life for the COVERED PERSON. New York Life will have the right to withdraw approval of a COVERED PERSON S participation before the end of any such period by advance written notice to the COVERED PERSON and the COVERED PERSON S participation will terminate, in such event on the termination date stated in the notice. While an INSURED MEMBER is receiving the Rehabilitation Benefit, insurance will continue without the payment of CONTRIBUTIONS. Repatriation Benefit - If a COVERED PERSON S death occurs outside the territorial limits of the state or country of his or her permanent residence, and is a Covered Loss, the Plan will pay a Repatriation Benefit. The benefit is the lesser of: (a) 25% of the COVERED PERSON S Principal Sum; or (b) $25,000. The Repatriation Benefit is limited to the: (a) preparation of the body for burial or cremation; and (b) transportation of the body to the place of burial or cremation. Seat Belt Benefit - New York Life will pay an additional benefit if a COVERED PERSON S death is a Covered Loss and such COVERED PERSON dies as a result of injuries sustained in an accident, provided the death occurs within 365 days of the accident, while: (a) traveling in a Private Passenger Car; (b) the seatbelt was in proper use by the COVERED PERSON at the time of the accident as certified in the accident report or by the investigating officer; and (c) the driver of the Private Passenger Car was a licensed driver and was not intoxicated, impaired or under the influence of alcohol or drugs. The benefit amount is the lesser of: (a) 50% of the COVERED PERSON S Principal Sum amount; or (b) $50,000. A copy of the accident report made out by the police must be submitted to New York Life. Private Passenger Car means a validly registered four-wheeled privately owned or Employer-owned car, jeep, pickup truck or van, including a sport utility vehicle (SUV), that is not licensed commercially or being used for racing, or acrobatic or stunt driving. Air Bag Benefit If the Seat Belt Benefit is payable as stated above, New York Life will pay an additional benefit if the COVERED PERSON was positioned in a seat protected by a properly functioning, original, factory-installed airbag system that inflates on impact when the accident occurred. The benefit amount is the lesser of: (a) 10% of the COVERED PERSON S Principal Sum Amount; or (b) $25,000. Spouse Critical Period Benefit If an INSURED MEMBER and his or her INSURED SPOUSE are covered under the Policy and: (a) either person s death is a Covered Loss; and (b) either spouse survives; New York Life will pay an additional benefit equal to 1% of the deceased COVERED PERSON S Principal Sum. The benefit is payable monthly to the SURVIVOR SPOUSE and is payable until the earlier of: (a) six consecutive months; or (b) the date the SURVIVOR SPOUSE dies. Beneficiary Covered Loss Except as stated below, the benefit payable for a COVERED PERSON S Covered Loss, other than for his or her loss of life, will be paid to the INSURED MEMBER. G GMR-ADD

8 AD&D INSURANCE The benefit payable for an INSURED MEMBER S loss of life will be paid in accordance with the Death Benefit subsection of the Beneficiary section. Death Benefit Except as stated below, the Death Benefit will be paid to the designated beneficiary(ies). However, if at the time of the COVERED PERSON S death there is no surviving beneficiary for any designated share of the Death Benefit, such share will be paid to the executor or administrator of the COVERED PERSON S estate, or at the option of New York Life, to the COVERED PERSON S surviving relative(s) in the following order of survival: lawful married spouse; children equally; parents equally; or brothers and sisters equally. In addition, if a beneficiary dies within 15 days after the COVERED PERSON, New York Life will consider such beneficiary to have predeceased such COVERED PERSON, if payment has not already been made. For MEMBER INSURANCE, the INSURED MEMBER can designate a beneficiary or change his or her beneficiary designation. For an INSURED DEPENDENT, the automatic beneficiary is the INSURED MEMBER. One or more beneficiaries can be designated. If more than one beneficiary is designated, they can be classified as Primary Beneficiary ("Primary Beneficiary" is the person(s) named to first receive the proceeds of the insurance), or Contingent Beneficiary ("Contingent Beneficiary" is the person(s) named to receive the proceeds of the insurance if no Primary Beneficiary survives. Each beneficiary s share can be stated. If more than one beneficiary is designated and if their respective interests have not been stated, they will share alike. Facility Of Payment - New York Life has the right to pay up to $250 of the benefit to anyone who has incurred expenses for the COVERED PERSON'S fatal accident or burial ("payee"). Forfeiture Of Payment - No payment will be made to any person(s) if such person(s) is the principal or an accomplice in willfully bringing about the death of the COVERED PERSON. Payment will be made in accordance with this section as though that person(s) had died before the COVERED PERSON. Payment In Installments Any COVERED PERSON who can designate a beneficiary can elect to have all or any part of the benefit payable in the event of his or her death paid in installments. He or she can later revoke or change such election. After the COVERED PERSON S death, his or her beneficiary can elect to have all or any part of the Death Benefit or Covered Loss benefit, to which he or she is entitled, paid in installments, if: (a) the COVERED PERSON did not elect payment in installments; (b) the beneficiary is an adult natural person; and (c) no payment has been made. The beneficiary can later revoke or change his or her election. The amount and terms of the installments will be in accordance with New York Life s standard practices at the time of such election or change. Transfer Of Ownership An INSURED MEMBER can transfer all incidents of ownership of his or her AD&D Insurance. The Policyholder agrees to accept CONTRIBUTIONS directly from the transferee. Except as stated in this section, an INSURED MEMBER S insurance cannot be transferred or assigned. Request Procedure To: (a) designate a beneficiary or change a beneficiary designation; and/or (b) transfer ownership; New York Life must be given a completed, written request on a form satisfactory to it. Such request must be approved and recorded by or on behalf of New York Life. After such recording, the request will take effect as of the date it was signed, subject to any payment made or any other action taken by or on behalf of New York Life before the recording. Requests in effect under the PREVIOUS POLICY for TRANSFER INSURANCE will remain in effect under the Policy until changed. G GMR-ADD

9 WHEN INSURANCE ENDS Except as stated on the Continuance page(s), a COVERED PERSON'S insurance will end on the earliest of: 1. the last day of the INSURANCE PERIOD during which the INSURED MEMBER is no longer a member of the ASSOCIATION; 2. the last day of the Grace Period, stated below, that follows the end of the INSURANCE PERIOD for which the last CONTRIBUTION has been paid for the COVERED PERSON; Grace Period The COVERED PERSON is entitled to a Grace Period of 31 days for the payment of each CONTRIBUTION due except for the first. During the Grace Period, the COVERED PERSON S insurance continues in force. If the CONTRIBUTION due is not paid before the end of the Grace Period, the COVERED PERSON S insurance automatically ends on the last day of such Grace Period. 3. the date the Principal Sum is paid for the COVERED PERSON; 4. for an INSURED DEPENDENT, the date the INSURED MEMBER'S MEMBER INSURANCE ends, except that: the INSURED MEMBER may choose to continue his or her DEPENDENT INSURANCE if such MEMBER INSURANCE ended because of payment of the Principal Sum; 5. for an INSURED SPOUSE, the last day of the INSURANCE PERIOD during which such INSURED SPOUSE ceases to be the lawful, married spouse of the INSURED MEMBER; 6. for an INSURED CHILD, the last day of the INSURANCE PERIOD during which such INSURED CHILD: (a) reaches the TERMINATION AGE DATE; (b) marries; (c) becomes an INSURED MEMBER; or (d) with respect to a stepchild, is no longer substantially dependent upon the INSURED MEMBER for support; or with respect to a natural child, stepchild, or adopted child, if the INSURED MEMBER is deceased, is no longer substantially dependent upon the family for support; 7. the later of: (a) the date stated in the COVERED PERSON S written request to end the insurance; or (b) the date New York Life receives the COVERED PERSON S written request to end the insurance; or 8. the day before the day the Policy ends or is changed to end insurance for the group of insureds to which the COVERED PERSON belongs. G GMR-ENDS CONTINUANCE Insurance in force on each COVERED PERSON will continue, after the date it would otherwise have ended as stated on the When Insurance Ends page(s), in accordance with all of the following: Handicapped Child Benefit Insurance in force will continue for an INSURED CHILD who has: (a) reached the TERMINATION AGE DATE and (b) a Handicap ("Handicap" means a physical or mental disability which: (1) renders the INSURED CHILD incapable of self-sustaining employment; and (2) requires dependency on the INSURED MEMBER or other care provider(s) for support or, in the event of the INSURED MEMBER'S death, on the family or other care provider(s) for support); if: 1. New York Life receives satisfactory proof of such Handicap within 31 days after the date such child's insurance would otherwise have ended due to reaching the TERMINATION AGE DATE; and 2. the CONTRIBUTION is paid. G GMR-L/ADD C

10 CONTINUANCE The benefit will end on the earliest of the following: 1. the last day of the INSURANCE PERIOD during which such child is no longer so Handicapped; 2. the date New York Life does not receive the required proof that such child remains Handicapped as required by New York Life but no more frequently than annually; or 3. the date insurance would otherwise end as stated on the When Insurance Ends page(s). Survivor Spouse Benefit SPOUSE INSURANCE or DEPENDENT INSURANCE in force on an INSURED SPOUSE and INSURED CHILD on the day the INSURED MEMBER dies will continue, if the CONTRIBUTION is paid. Insurance in force for only an INSURED CHILD will not continue. The SURVIVOR SPOUSE S insurance will automatically increase to that for which the deceased INSURED MEMBER s was insured. All insurance criteria, including but not limited to termination age, reductions of insurance, and amount of CONTRIBUTION, will be based on the SURVIVOR SPOUSE S age. The benefit will end on the date insurance would otherwise end as stated on the When Insurance Ends page(s). G GMR-L/ADD C DEFINITIONS AGE means the attained age on the first day of any INSURANCE PERIOD. References to Age in any heading means "AGE". APPLICANT means an ELIGIBLE MEMBER or an INSURED MEMBER who meets the requirements of an ELIGIBLE MEMBER. ASSOCIATION means The Institute Of Electrical And Electronics Engineers, Inc. ( IEEE ) CERTIFICATE EFFECTIVE DATE means the date that insurance takes effect as stated in the For Insurance To Take Effect section of the When Insurance Takes Effect page. CONTRIBUTION means the applicable full periodic payment toward the premium, received by the Policyholder, which is necessary for insurance to take effect on the CERTIFICATE EFFECTIVE DATE and/or for insurance to continue in force under the Policy. CONTRIBUTION is determined by the Policyholder and is due on each RENEWAL DATE. COVERED PERSON means an INSURED MEMBER or an INSURED DEPENDENT. DEPENDENT INSURANCE means an INSURED MEMBER'S insurance for his or her INSURED DEPENDENT(S). ELIGIBLE DEPENDENT means a person who is in one of the following classes: Class 1: An APPLICANT'S: 1. lawful married spouse, who: a. is identified on the request for group insurance; b. has not exceeded the MAXIMUM ELIGIBILITY AGE; c. is not a resident of an EXCLUDED STATE; d. is not an ELIGIBLE MEMBER; and e. is not eligible to become insured under the Policy for TRANSFER INSURANCE as a dependent; or G GMR-DEF

11 DEFINITIONS Class 2: 2. natural child, stepchild, or adopted child, who: a. is not married; b. with respect to the stepchild, is substantially dependent upon the APPLICANT for support; or if the APPLICANT is deceased, the natural child, stepchild, or adopted child is substantially dependent upon the family for support; c. is at least 14 days old; d. has not exceeded the MAXIMUM ELIGIBILITY AGE; e. is not a resident of an EXCLUDED STATE, except that this requirement does not apply if the APPLICANT has DEPENDENT INSURANCE in force for children; f. is not an ELIGIBLE MEMBER; and g. is not eligible to become insured under the Policy for TRANSFER INSURANCE as a dependent; or An ELIGIBLE MEMBER'S: 1. spouse, identified on the request for group insurance; or 2. unmarried child(ren) ; who has not reached the TERMINATION AGE DATE on the TRANSFER DATE, who was insured as a dependent under the PREVIOUS POLICY and for whom such ELIGIBLE MEMBER has TRANSFER INSURANCE. If both parents of an ELIGIBLE CHILD are INSURED MEMBERS, such child will be considered an ELIGIBLE DEPENDENT of only one parent. References to an adopted child include a child who is in the custody of the APPLICANT, pursuant to an interim court order of adoption or placement of adoption, whichever comes first, which vests temporary care of the child with the APPLICANT regardless of whether a final order granting adoption is finally issued. References to ELIGIBLE SPOUSE and ELIGIBLE CHILD(REN) mean the same as ELIGIBLE DEPENDENT spouse and ELIGIBLE DEPENDENT child(ren), respectively. ELIGIBLE MEMBER means a person who is in one of the following classes: Class 1: Class 2: A person who: 1. is a member of the ASSOCIATION; 2. has not exceeded the MAXIMUM ELIGIBILITY AGE; 3. is not a resident of an EXCLUDED STATE; and 4. is not eligible to become insured under the Policy for TRANSFER INSURANCE; or 1. is a member of the ASSOCIATION; and 2. a person who has TRANSFER INSURANCE. EXCLUDED STATE means: (a) the Province Of Quebec; and (b) anywhere else, except the fifty states of the United States Of America, the District Of Columbia, Puerto Rico or any other province of the Dominion Of Canada. INSURANCE PERIOD means the span of time from a RENEWAL DATE through the day before the next RENEWAL DATE, during which insurance continues, if the CONTRIBUTION for such span of time is paid. INSURED DEPENDENT means a person who: (a) was an ELIGIBLE DEPENDENT on his or her first CERTIFICATE EFFECTIVE DATE; (b) became insured under the Policy, as approved by New York Life; and (c) remains insured under the Policy, including as a SURVIVOR DEPENDENT. References to INSURED SPOUSE and INSURED CHILD(REN) mean the same as INSURED DEPENDENT spouse and INSURED DEPENDENT child(ren), respectively. INSURED MEMBER means a person who: (a) was an ELIGIBLE MEMBER on his or her first CERTIFICATE EFFECTIVE DATE; (b) became insured under the Policy, as approved by New York Life; and (c) remains insured under the Policy. References to INSURED MEMBER mean the Owner for the incidents of ownership. ("Owner" means the person who has the rights of ownership of the insurance.) G GMR-DEF

12 DEFINITIONS MAXIMUM ELIGIBILITY AGE means the oldest a person can be and still be initially eligible for insurance, as follows: ELIGIBLE MEMBER, through age 69; ELIGIBLE SPOUSE, through age 69; or ELIGIBLE CHILD, through age 18, or through age 25 if a full-time student. MEMBER INSURANCE means an INSURED MEMBER'S insurance for himself or herself. PREVIOUS POLICY means Group Policy Number G issued to the Policyholder by New York Life Insurance Company. RENEWAL DATE means the following dates on or before which the CONTRIBUTION must be paid to the Policyholder: 1. initially: (a) the CERTIFICATE EFFECTIVE DATE; or (b) if by agreement between the Policyholder and New York Life and without individual selection, within 31 days after the CERTIFICATE EFFECTIVE DATE; and 2. thereafter, the applicable annual, semiannual, quarterly, or monthly date based on the mode of payment elected by the INSURED MEMBER and accepted by the Policyholder. Modes of payment in effect under the PREVIOUS POLICY for TRANSFER INSURANCE will remain in effect under the Policy until changed. SURVIVOR DEPENDENT means an INSURED DEPENDENT of a deceased INSURED MEMBER. References to SURVIVOR SPOUSE and SURVIVOR CHILD(REN) mean the same as SURVIVOR DEPENDENT spouse and SURVIVOR DEPENDENT child(ren), respectively. TERMINATION AGE DATE means the date insurance for an INSURED CHILD ends due to his or her attainment of the stated AGE: the last day of the INSURANCE PERIOD during which the INSURED CHILD reaches AGE 19, or if the child is a full-time student, reaches AGE 26, or any other age up to AGE 26 if the child is no longer a full-time student. TRANSFER DATE means, for each ELIGIBLE MEMBER with TRANSFER INSURANCE: January 1, 2011 or any other date agreed to by the Policyholder and New York Life if the ELIGIBLE MEMBER transfers from PREVIOUS POLICY G prior to the January 1, 2011 TRANSFER DATE. TRANSFER INSURANCE means the member insurance or member and dependent insurance in force: (a) on December 31, 2010 or the day before any other agreed to TRANSFER DATE; and (b) which is being transferred to the Policy on such TRANSFER DATE. G GMR-DEF

13 SCHEDULE ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE The Principal Sum available to each COVERED PERSON is as follows:* Insured Member $50,000 through $500,000 is available in $50,000 multiples Each Insured Dependent The following percentage of the Member s Principal Sum: Insured Spouse Only Insured Spouse and Insured Child(ren) Insured Child(ren) Only 60% Insured Spouse 50% 15% Insured Child(ren) 10% Table Of Benefits Percentage of Covered Loss Principal Sum loss of life 100% loss of two limbs 100% loss of sight of both eyes 100% loss of speech and hearing 100% loss of movement of both upper and lower limbs (quadriplegia) 100% loss of movement of both lower limbs (paraplegia) 75% loss of movement of both upper and lower limbs 50% on one side of the body (hemiplegia) loss of one limb 50% loss of sight of one eye 50% loss of speech or hearing 50% loss of thumb and index finger on one hand 25% Loss of sight, speech or hearing means total and permanent loss. Loss of limb means severance through or above the wrist or ankle. Loss of thumb and index finger means severance through or above the metacarpophalangeal joints. Loss of movement of limbs means total and permanent paralysis of such limbs. Maximum The maximum for each COVERED PERSON while he or she is insured under the Policy is as follows: No more than one benefit, the largest benefit, is payable for all losses to the same limb due to or related to any one accident No more than the Principal Sum is payable for all losses due to or related to any accident, except as otherwise provided under the What Benefit Is Payable section on the AD&D Insurance page(s). POLICY MAXIMUM - A COVERED PERSON may not be insured under the Policy for an amount of insurance that exceeds $500,000. AGGREGATE MAXIMUM An individual may not be insured under one or more Group Policies issued by New York Life for an amount of AD&D Insurance that exceeds New York Life s overinsurance standards that apply to Group AD&D Insurance. These overinsurance standards are included in New York Life s group underwriting guidelines. * TRANSFER INSURANCE on each INSURED MEMBER will equal the amount of insurance in effect on the day before the TRANSFER DATE. If this amount of insurance is not already a multiple of $50,000 then the amount will be rounded to the nearest $50,000. However, the INSURED DEPENDENT S amount of insurance will be changed to a percentage of the INSURED MEMBER S amount of insurance. G /1/10 GMR-S

14 SCHEDULE Summary of Covered Losses Adaptive Home/Auto Benefit Maximum Amount: $5,000 Percentage of Principal Sum: 5% Burn Disfigurement Maximum Amount: $30,000 Percentage of Principal Sum: 10% Elder Care Benefit Maximum Amount: $5,000 Percent of Principal Sum: 5% Rehabilitation Benefit Maximum Amount: $10,000 Percent of Principal Sum: 10% Common Carrier Benefit $25,000 Repatriation Benefit Maximum Amount: $25,000 Percent of Principal Sum: 25% Common Disaster Benefit Common Disaster Limit $500,000 INSURED MEMBER and INSURED SPOUSE combined Seat Belt Benefit Maximum Amount: $50,000 Percent of Principal Sum: 50% Day Care Benefit Maximum Amount: $2,500 Percentage of Principal Sum: 5% Maximum Benefits 4 per child Education Benefit Maximum Amount: $2,500 Percentage of Principal Sum: 2% Maximum Benefits 4 per student Air Bag Benefit Maximum Amount: $25,000 Percent of Principal Sum: 10% Spouse Critical Period Benefit Percent of Principal Sum: 1% for six months Conversion to Common Carrier Travel Accident Insurance only at Age 70 with Reduction in Insurance When an INSURED MEMBER or SURVIVOR SPOUSE reaches AGE 70, insurance converts to Common Carrier Travel Accident Insurance only. Any Principal Sum in excess of $100,000 reduces to $100,000. Common Carrier Travel Accident Insurance means the Principal Sum or applicable percentage is payable only for a Covered Loss which is the result of an accident while traveling in a conveyance operated by a concern, if: (a) such concern is organized and licensed for the transportation of passengers for hire; and (b) such conveyance is operated by an employee of such concern. G /1/10 GMR-S